Note: This copy is for your personal non-commercial use only. To order presentation-ready
copies for distribution to your colleagues or clients, contact us at www.rsna.org/rsnarights.
MUSCULOSKELETAL IMAGING
791
Biceps Pulley: Normal
Anatomy and Associated Lesions at MR
Arthrography1
Waka Nakata, MD • Sakura Katou, MD • Akifumi Fujita, MD • Manabu
Nakata, MD • Alan T. Lefor, MD, MPH • Hideharu Sugimoto, MD
The biceps pulley or “sling” is a capsuloligamentous complex that acts
to stabilize the long head of the biceps tendon in the bicipital groove.
The pulley complex is composed of the superior glenohumeral ligament, the coracohumeral ligament, and the distal attachment of the
subscapularis tendon, and is located within the rotator interval between the anterior edge of the supraspinatus tendon and the superior
edge of the subscapularis tendon. Because of its superior depiction
of the capsular components, direct magnetic resonance arthrography
is the imaging modality of choice for demonstrating both the normal
anatomy and associated lesions of the biceps pulley. Oblique sagittal
images and axial images obtained with a high image matrix are valuable for identifying individual components of the pulley system. Various pathologic processes occur in the biceps pulley as well as the rotator interval. These processes can be traumatic, degenerative, congenital, or secondary to injuries to the surrounding structures. The term
hidden lesion refers to an injury of the biceps pulley mechanism and is
derived from the difficulty in making clinical and arthroscopic identification. Pathologic conditions associated with pulley lesions include
anterosuperior impingement, instability of the biceps tendon, biceps
tendinopathy or tendinosis, superior labrum anterior and posterior lesions, and adhesive capsulitis. It is important to be familiar with the
normal appearance of the biceps pulley so that abnormalities can be
correctly assessed and effectively managed.
©
RSNA, 2011 • radiographics.rsna.org
Abbreviations: ASI = anterosuperior impingement, CHL = coracohumeral ligament, GHL = glenohumeral ligament, LBT = long head of the biceps
tendon, SLAP = superior labrum anterior and posterior
RadioGraphics 2011; 31:791–810 • Published online 10.1148/rg.313105507 • Content Codes:
From the Departments of Radiology (W.N., S.K., A.F., M.N., H.S.) and Surgery (A.T.L.), Jichi Medical University School of Medicine, 3311-1
Yakushiji, Shimotsuke-shi, Tochigi-ken 329-0498, Japan. Presented as an education exhibit at the 2009 RSNA Annual Meeting. Received February 1,
2010; revision requested March 24; final revision received August 29; accepted September 14. All authors have no financial relationships to disclose.
Address correspondence to W.N. (e-mail: waka-s@jichi.ac.jp).
1
©
RSNA, 2011
792 May-June 2011
radiographics.rsna.org
Figure 1. Normal anatomy. Ac = acromion, Cl = clavicle, Cp = coracoid process, GT = greater tuberosity,
SBT = short head of the biceps tendon. (a) Drawing illustrates the anatomy of the glenohumeral joint.
CHL = coracohumeral ligament, Ssc = subscapularis tendon, Ssp = supraspinatus tendon, Tr = transverse
humeral ligament, 1 = acromioclavicular ligament, 2 = coracoclavicular ligament, 3 = coracoacromial ligament. (b) Cadaveric photograph (anterolateral view) shows the coracoacromial ligament (*) extending
from the coracoid process to the acromion. Arrowheads indicate the extraarticular portion of the LBT.
Del = deltoid muscle, PM = pectoralis major muscle.
Introduction
Abnormalities of the rotator interval are increasingly being recognized as causes of shoulder pain
and discomfort. Within this anatomic area lies
a complex pulley system that stabilizes the long
head of the biceps tendon (LBT). The difficulties in clinical and arthroscopic evaluation of this
region highlight the importance of both pre- and
posttreatment imaging assessment (1). Although
lesions of the biceps pulley can optimally be imaged with magnetic resonance (MR) arthrography, they are frequently overlooked or inaccurately assessed, and, if left untreated, they may
result in persistent shoulder pain. Recognizing
the complex anatomy of the pulley system and its
close association with the surrounding structures,
as well as understanding the mechanisms and
patterns of injury, are essential for guiding appropriate case management.
In this article, we discuss the biceps pulley in
terms of normal anatomy, function, MR imaging
techniques, and MR arthrographic features. In
addition, we discuss the MR arthrographic findings of various pathologic processes found in the
anterosuperior aspect of the shoulder, and correlate these findings with arthroscopic findings.
Normal Anatomy
Glenohumeral Joint
The glenohumeral joint consists of the spheric
head of the humerus and the shallow glenoid
fossa of the scapula. It is known as the most mobile joint in the body and the most frequently
dislocated large joint, owing to its relative lack of
osseous constraints. Its stability, both static and
dynamic, depends on the surrounding muscle
and soft-tissue structures (2,3).
Glenoid Labrum
As a fibrocartilaginous extension of the glenoid
fossa, the glenoid labrum deepens and increases
the surface area of the glenohumeral articulation. It varies in size and thickness, with a base
that is attached to the margin of the fossa and
is triangular in cross section. The labral attachment is sometimes partially deficient anterosuperiorly (2,3).
Joint Capsule
A fibrous capsule is attached medially to the glenoid neck outside the glenoid labrum and laterally to the anatomic neck of the humerus (except inferiorly, where it attaches to the humeral
shaft). Superiorly, the capsule encroaches on
the coracoid process to include the attachment
RG • Volume 31
Number 3
Nakata et al
793
Figure 2. Normal anatomy. Ac = acromion, Ssc = subscapularis tendon, Ssp = supraspinatus tendon.
(a) Drawing illustrates the deeper structures of the rotator interval (circled) after the superficial ligaments
have been removed. Cap = joint capsule, CHL = coracohumeral ligament, Cl = clavicle, Cp = coracoid process, Lat. band = lateral band of the CHL, Med. band = medial band of the CHL, Tr = transverse humeral
ligament. (b) In the corresponding cadaveric photograph, the conjoined tendon of the coracobrachialis
muscle and the short head of the biceps brachialis muscle (arrow) is flipped superiorly, the supraspinatus
tendon is flipped posteriorly, and the coracoacromial ligament is cut at its insertion at the acromion (arrowhead). The rotator interval (dotted outline) is covered by the coracohumeral ligament (CHL) and the
extraarticular portion of the LBT (*).
Figure 3. (a) Drawing illustrates the normal anatomy of the biceps pulley. The CHL is cut
so that the superior glenohumeral ligament (SGHL), focal capsular thickening, and the
intraarticular portion of the LBT can be seen. Ac = acromion, Cl = clavicle, Cp = coracoid
process, GT = greater tuberosity, LT = lesser tuberosity, Ssc = subscapularis tendon, Ssp
= supraspinatus tendon. (b) In the corresponding cadaveric photograph (anterolateral view),
the subscapularis tendon (arrows) and the joint capsule (arrowhead) are cut. Cp = coracoid
process, dotted line indicates the rotator interval.
of the LBT (3,4). The capsule of the glenohumeral joint is lax and somewhat redundant, and
although this configuration maximizes the range
of motion of the upper extremity, it also contributes to potential instability of the glenohumeral
joint. There are several ligaments and tendons
that reinforce the capsule, from both the inside
and outside (Figs 1–3).
794 May-June 2011
radiographics.rsna.org
Figure 4. (a) Drawing illustrates the intraarticular portion of the shoulder without the humeral
head. Ac = acromion, Cl = clavicle, Cp = coracoid process, 1 = supraspinatus tendon, 2 = infraspinatus
tendon, 3 = teres minor tendon, 4 = subscapularis tendon, 5 = LBT, 6 = superior GHL, 7 = middle
GHL, 8 = anterior band of the inferior GHL, 9 = posterior band of the inferior GHL, 10 = glenoid
labrum, 11 = CHL, 12 = superior subscapularis recess, 13 = subacromial bursa, 14 = subcoracoid
bursa, 15 = short head of the biceps tendon, 16 = coracobrachialis tendon, 17 = coracoacromial ligament, 18 = coracoclavicular ligament. (b) Corresponding cadaveric photograph shows the proximal
portion of the LBT (black *), the superior GHL (black arrow), and the middle GHL (arrowhead).
The superior subscapularis recess (white *) is seen between the capsule and the subscapularis muscle
(white arrow). The joint capsule is cut at its proximal portion (cf Fig 7).
Capsular Ligaments
The three glenohumeral ligaments (GHLs)—superior, middle, and inferior—are bandlike collagenous thickenings of the capsule that reinforce
the (thin) capsule and can be seen only from
within the joint (Fig 4). The superior GHL is the
most consistently identified capsular ligament
(2). It originates from the superior glenoid tubercle just anterior to the origin of the biceps tendon. The CHL originates at the coracoid process
and courses posteriorly and laterally to fuse with
the joint capsule. It runs parallel to the superior
GHL and inserts into the lesser tuberosity (2).
through the intertubercular sulcus (bicipital
groove). The conjoined distal tendon of the short
and long heads inserts onto the radial tuberosity
below the level of the elbow (3). Because of the
anatomic position of the bicipital groove both
medially and ventrally in relation to the scapula,
the biceps serves as a rather ineffectual elevator
of the arm. The site of origin of the long head is
variable. Attachment to the posterosuperior labrum, the glenoid tubercle, or both may be seen.
The labral attachment is further subdivided,
arising mainly posteriorly, mainly anteriorly, or
equally from both locations (5).
Long Head of the Biceps Tendon
Rotator Cuff
As its name implies, the biceps brachii muscle
has two separate origins. The short head of the
biceps tendon is extraarticular in location and
arises from the apex of the coracoid process
along with the coracobrachialis tendon. The
LBT arises within the glenohumeral joint from
the supraglenoid tubercle of the scapula, and
the glenoid labrum within the capsule (Figs 1,
5). It traverses the rotator interval and descends
The four constituent muscles of the rotator cuff
originate from the scapula and wrap around the
humeral head as they insert onto the proximal
humerus. These muscles include the subscapularis muscle anteriorly, the infraspinatus and
teres minor muscles posteriorly, and the supraspinatus muscle superiorly. The musculotendinous cuff is firmly attached to the underlying
joint capsule, except at the rotator interval and
axillary recess, and reinforces the joint capsule
from the outside (Fig 2) (6).
RG • Volume 31
Number 3
Nakata et al
795
Rotator Interval and Biceps Pulley
Figure 5. Biceps anchor. Cadaveric photograph (lateral view) shows the origin of the biceps tendon (white
arrow) and the superior GHL (black arrow). The CHL
(black arrowhead) is seen just above the biceps tendon.
White arrowhead indicates the cut subscapularis tendon
(cf Fig 3b).
Figure 6. Cadaveric photograph (posterolateral view)
shows the intraarticular ligaments and outer supporting
structures. The roof of the rotator interval is covered by
the CHL (arrowheads) and the joint capsule (Cap). The
proximal portion of the LBT (*) courses into the bicipital groove (not shown) together with the middle GHL
(straight arrow) and the anterior band of the inferior
GHL (curved arrow). Isp = infraspinatus tendon, Ssp =
supraspinatus tendon, TM = teres minor tendon.
Coracoacromial Ligament
The coracoacromial ligament is a strong, triangular fibrous band that extends from the coracoid
process to the acromion (Fig 1). Together with
the coracoid process and the acromion, it forms a
protective arch superficial to the rotator cuff (3).
The shape of the ligament varies (6).
The triangular space between the superior border of the subscapularis tendon and the anterior
border of the supraspinatus tendon is termed the
rotator interval. The intraarticular portion of the
LBT courses through the rotator interval (Fig 2)
(7–10). In this article, the anterior rotator interval is referred to simply as the rotator interval.
The apex and the base of the rotator interval are
formed by the transverse ligament bridging the
bicipital groove and the coracoid process with the
origin of the CHL medially, respectively (7–10).
The rotator interval represents a defect in the
rotator cuff resulting from the protrusion of the
coracoid process between the supraspinatus and
infraspinatus tendons. This portion of the glenohumeral joint capsule is not reinforced by overlying rotator cuff muscles.
The CHL originates from the lateral aspect
of the base of the coracoid process. It courses
through the rotator interval and forms two discrete
bands distally. The larger (lateral) band blends
into the greater tuberosity and the fibers of the
supraspinatus tendon. The smaller (medial) band
crosses over the biceps tendon to insert at the
proximal aspect of the lesser tuberosity, forming
an anterior covering around the biceps tendon,
where it blends with the fibers of the subscapularis
tendon. Variable types of insertion are described,
including (a) insertion into the rotator interval,
(b) insertion to either the supraspinatus tendon
or the subsucapularis tendon, or (c) insertion to
both the supraspinatus and subscapularis tendons
(2,11). The CHL is the most superficial capsular
structure of the rotator interval. It blends with the
fibers of the subscapularis and supraspinatus tendons at their insertions.
The superior GHL originates from the superior
glenoid tubercle just anterior to the biceps tendon.
Laterally, it forms a U-shaped “sling” that crosses
underneath the biceps tendon and inserts into the
lesser tuberosity, where it blends with the CHL.
The insertion fibers of the superior GHL extend
inferiorly to the superior margin of the subscapularis tendon and blend with the fibers of the subscapularis tendon at the lesser tuberosity (8).
The LBT may arise from the posterosuperior
labrum, the superior glenoid tubercle, or both
(Figs 3, 5). As the tendon passes laterally through
the rotator interval, it is surrounded by the CHL
superiorly and the superior GHL anteriorly, forming a slinglike band (Figs 6, 7) (5,12). When the
796 May-June 2011
radiographics.rsna.org
Figure 7. Biceps pulley. C = subscapularis tendon, D = middle GHL. (a) Cadaveric photograph
(superoposterior view) shows that the rotator cuff has been cut between the supraspinatus tendon
(A) and infraspinatus tendon and has been lifted. Note how the inferior wall of the biceps pulley
is formed by the subscapularis tendon, the anterior wall by the superior GHL (B), and the superior
wall by the CHL. Dotted line indicates the rotator interval. E = infraspinatus tendon, F = posterior
band of the inferior GHL. (b) Cadaveric photograph (superoposterior view) shows the distal insertion of the superior GHL to the humeral head (arrow).
Figure 8. Cadaveric photographs (superolateral view) show the floor of the biceps pulley. The distal
insertion of the superior GHL to the humeral head (arrow) is seen from a different angle than in
Figure 4c. The LBT (*) has been pulled slightly anterior to allow a better view. The distal insertion
of the supraspinatus tendon (Ssp) is also depicted (arrowhead in b).
biceps tendon approaches the distal end of the
capsule, the bicipital groove, the conjoined fibers
of the superior GHL and joint capsule form the
floor of the tendon (Fig 8) (5). The role of the
transverse humeral ligament remains controversial. Many authors do not believe that it is a major
contributor to stabilization of the biceps tendon in
the bicipital groove (1,10,13). Gleason et al (14)
conducted a cadaveric study and discovered no
separate anatomic structures bridging the bicipital
groove. Instead, the fibers covering the bicipital
groove are composed of a sling formed mainly by
the fibers of the subscapularis tendon, with contributions from the supraspinatus tendon and the
CHL (14). Similarly, in a study of 85 cadaveric
shoulders, MacDonald et al (15) found no distinct
transverse humeral ligament. They stated that in
only 8% of cases did the subscapularis tendon
RG • Volume 31
Number 3
Nakata et al
797
Figures 9–11. (9) Rotator cuff. Oblique sagittal fat-saturated T1-weighted MR arthrographic image clearly
depicts the four muscles of the rotator cuff. The CHL (white arrow) and superior GHL (black arrow) form a
sling around the LBT (arrowhead). Ac = acromion, Del = deltoid muscle, Isp = infraspinatus tendon, Ssc = subscapularis tendon, Ssp = supraspinatus tendon, TM = teres minor muscle. (10) Axial fat-saturated T1-weighted
MR arthrographic image shows the intraarticular portion of the LBT (arrowhead). The superior GHL (arrow)
can be displaced medially to a varying extent depending on the degree of joint distention. Del = deltoid muscle.
(11) Oblique coronal fat-saturated T1-weighted MR arthrographic image of the biceps anchor shows how the
biceps tendon (white arrowheads) originates at the supraglenoid tubercle and the superior glenoid labrum. The
superior GHL (black arrowhead) arises immediately anterior to the biceps anchor but may not always be identifiable in the oblique coronal plane. The supraspinatus tendon (white arrow) is seen above the humeral head,
and the anterior band of the inferior GHL (black arrow) is seen as a thick band forming the anterior margin of
the axillary recess. Cl = clavicle, G = glenoid, * = incidentally discovered benign intraosseous lesion.
MR Imaging Assessment
insert exclusively onto the lesser tuberosity. They
suggested that what was once thought to be a
transverse humeral ligament is actually combined
fibers from the subscapularis tendon and posterior lamina of the tendon of the pectoralis major
muscle (15). The medial band of the CHL and the
superior GHL inserting on the lesser tuberosity,
together with the superior fibers from the subscapularis tendon, act as a pulley to stabilize the
biceps tendon in the bicipital groove. This entity
is also referred to as the biceps reflective pulley or
sling (7,9,10,12).
The biceps pulley is composed of several small
anatomic structures that lie very close to one another and actually blend together at their distal
attachment sites. Consequently, these structures
can be difficult to evaluate using conventional
MR imaging. Direct MR arthrography has been
shown to be the imaging modality of choice for
identifying the normal anatomy and depicting lesions of the pulley mechanism. Chung et al (16)
conducted a study of pre- and postarthrographic
MR images obtained in 32 cadaveric shoulders to
better define the anatomy and MR findings of this
area (16). They found that the rotator interval and
its capsular structures were better depicted using
direct MR arthrography. In their study, only the
extraarticular biceps tendon and some parts of
its intraarticular portion were seen at routine MR
imaging in all cases, whereas MR arthrography
demonstrated the entire biceps tendon, including
the intraarticular portion, in all cases. The authors
also stated that the CHL was seen in only 60% of
cases, and that in no case was the superior GHL
well delineated with routine MR imaging (16).
Both ligaments are identified at MR arthrography
in all cases (Figs 9–11). Because of its variety of
798 May-June 2011
radiographics.rsna.org
Figure 12. Biceps pulley lesion with a rotator cuff tear in a 34-year-old man who suffered an acute
injury from a fall. (a, b) Axial fat-saturated T1-weighted MR arthrographic images demonstrate absence of the superior GHL (arrow in a) and a swollen subscapularis tendon, along with contrast material insinuation indicating a partial tear of the subscapularis tendon (arrow in b). (c) Oblique sagittal fat-saturated T1-weighted MR arthrographic image also shows absence of the (torn) superior
GHL (black arrow) and a frayed and irregular superior margin of the subscapularis tendon (white
arrow). (d) Oblique coronal T2-weighted MR arthrographic image shows a tear of the supraspinatus
tendon (arrow). Subacromial impingement and rupture of the supraspinatus tendon were also confirmed with arthroscopy. (e) Arthroscopic photograph shows a rotator interval lesion (arrow). Fraying of the subscapularis tendon (not shown) was also confirmed. H = humeral head.
RG • Volume 31
Number 3
Nakata et al
799
insertion sites, the CHL may be difficult to visualize as a separate structure at MR imaging, especially at the insertion site.
Optimal standard MR imaging should include
images obtained in all three planes and aligned
with the glenohumeral joint. Oblique coronal images are suitable for evaluation of the rotator cuff
and labrum, but it is difficult to evaluate the rotator interval on these images. Oblique sagittal images obtained parallel to the plane of the glenoid
fossa and orthogonal to the long axis of the rotator
cuff are thought to be the best for evaluating the
rotator interval and its contents (Fig 9) (7). Axial
images are also valuable for identifying the biceps
pulley complex, along with the biceps tendon
within the proximal bicipital groove. The ligamentous pulley can be identified on cranial images
upon close examination (Fig 10). High-resolution
(<3 mm) sequences performed with a high image
matrix are recommended to optimize evaluation
of the individual structures of the biceps pulley
complex (9). Some authors have reported threedimensional fat-suppressed gradient-echo MR
imaging to be useful (17).
At our institution, intraarticular gadoliniumbased contrast material diluted with saline solution is injected under fluoroscopic guidance
with an anterior approach before MR imaging
is performed. Our standard shoulder imaging
protocol includes axial, oblique coronal, and
oblique sagittal fat-saturated T1-weighted imaging (repetition time msec/echo time msec =
660/11), axial and oblique coronal fast spin-echo
T2-weighted imaging (3360/82), and axial gradient-echo T2*-weighted imaging (550/15). Other
imaging parameters include a 15 × 15-cm field
of view, 3-mm section thickness, 0.6-mm intersection gap, and 215 × 300 matrix. A 1.5-T MR
imager and a dedicated shoulder surface coil are
used, and patients are positioned supine with the
shoulder in neutral position.
associated with each other. Therefore, disease
affecting any of the rotator interval components
may be part of a complex spectrum of pathologic conditions. Injury to any of these components requires that the entire rotator interval
system be evaluated. Clinical manifestations of
injury to this area may be nonspecific, and some
of the lesions may be missed at arthroscopy
(18). Persistent shoulder pain may result if these
“hidden lesions” are not identified preoperatively and addressed at the time of surgery (19).
Isolated rotator interval lesions have rarely been
described in the literature. Nobuhara and Ikeda
(20) observed rotator interval defects with subsequent inflammatory changes causing inferior instability. They identified two types of lesions: type
1, consisting of inflammation of the superficial
bursal area without instability; and type 2, consisting of extensive inflammation of deeper tissues in
the rotator interval with anterior instability. An
inflamed synovium, hypertrophy and elongation
of the middle GHL, possible tear of the ligament,
and granulation tissue over the biceps tendon as
well as on the undersurface of the superior aspect
of the subscapularis tendon were associated surgical findings in the cases they described (20). Some
authors have described rotator interval tears in association with shoulder instability, with secondary
impingement by the coracoacromial and coracoid
processes due to anterior subluxation of the joint
being the suggested cause (21). Le Huec et al (22)
described a traumatic tear of the rotator interval in
10 young patients. An associated partial tear of the
supraspinatus tendon was seen in only one patient.
All lesions were seen in the upper part of the subscapularis tendon near the lesser tuberosity.
Because the biceps pulley lies in the rotator
interval, there may be no substantial difference
between reported rotator interval lesions and biceps pulley lesions.
Pathologic Processes of
the Anterosuperior Shoulder
Instability of the LBT is closely related to biceps pulley lesions, with the specific pattern of
instability depending on the injured supporting structures. A pulley lesion can be caused by
degenerative changes, acute trauma, repetitive
microtrauma, or injury associated with a rotator
cuff tear (Figs 12, 13).
Rotator Interval Lesions
The structures that make up the rotator interval, including the LBT, labral-biceps anchor,
superior GHL, CHL, anterior margin of the supraspinatus tendon, superior margin of the subscapularis tendon, and joint capsule, are closely
Biceps Pulley Lesions
800 May-June 2011
radiographics.rsna.org
Figure 13. Bankart lesion with a superior GHL tear in a 35-year-old man who suffered recurrent
shoulder dislocations from skiing. (a) Axial fat-saturated T1-weighted MR arthrographic image shows
a classic Bankart lesion, with avulsion of the anteroinferior glenoid labrum (arrow). (b) Arthroscopic
photograph shows avulsion of the anterior glenoid labrum (arrow). A superior GHL tear was also
confirmed with arthroscopy. (c, d) Oblique sagittal (c) and axial (d) fat-saturated T1-weighted MR
arthrographic images show the superior GHL tear (arrow).
Baumann et al (18) performed a retrospective review of 1007 arthroscopies and found isolated pulley lesions in 7.1% of cases. The authors
(as have other investigators) described different
mechanisms of pathogenesis that led to the pulley
lesions. Traumatic injuries resulting from a fall on
an outstretched arm in combination with full external or internal rotation, a fall backward on the
hand or elbow, or direct anterior impact may cause
disruption of the pulley. The capsuloligamentous
complex may detach from the lesser tuberosity,
leading to anteromedial subluxation of the LBT
and, over time, injury to the biceps tendon itself.
A subscapularis tendon tear may also result from
these injuries (7,18,19,22). Chronic and repetitive
stress may also cause degenerative changes to the
pulley. This pattern of injury is seen in patients
who engage in overhead activity either occupationally or in association with sports. Large forces
of acceleration and deceleration in the throwing
motion are considered to cause damage. In this
type of injury, the constituents of the superficial
layer of the bicipital groove may be disturbed first
by a transverse humeral ligament tear or distal
subscapularis tendon tear. Biceps tendon laxity in
the bicipital groove may lead to superior extension of degenerative changes in the rotator interval (7,18,20). Potential causes of pulley lesions
include a congenital rotator interval defect (23), a
supratubercular ridge as an osseous protrusion of
the lesser tuberosity (24), or a shallow groove (5).
Anterosuperior Impingement
Gerber and Sebesta (25) first described anterosuperior impingement (ASI) as a form of intraarticular impingement responsible for painful structural
diseases of the shoulder. They described impingement of the deep surface of the subscapularis
tendon and the pulley against the anterosuperior
glenoid rim in a position of horizontal adduction
and internal rotation of the arm.
RG • Volume 31
Number 3
Nakata et al
801
Figure 14. Drawings (axial view) illustrate pulley lesions as defined by the
Habermeyer classification system. (a) Normal anatomy. G = glenoid, H =
humeral head, Ssc = subscapularis tendon, Ssp = supraspinatus tendon,
1 = CHL, 2 = LBT, 3 = superior GHL, 4 = lesser tuberosity, 5 = greater
tuberosity, 6 = anterior glenoid labrum. (b) Isolated superior GHL lesion
(group 1). (c) Superior GHL lesion with a partial articular-side supraspinatus tendon tear (group 2). The biceps tendon is slightly dislocated
anteriorly. (d) Superior GHL lesion with a partial articular-side subscapularis tendon tear (group 3). The biceps tendon is dislocated into the torn
subscapularis tendon. (e) Superior GHL lesion with partial articular-side
supraspinatus and subscapularis tendon tears (group 4). The biceps tendon
is dislocated completely outside the biceps pulley and is located in the torn
subscapularis tendon. (Fig 14 adapted from reference 12.)
Figure 15. (a–c) Habermeyer group 1 lesion in a 53-year-old man who suffered recurrent shoulder dislocations from surfing. Axial (a) and oblique
sagittal (b) fat-saturated T1-weighted MR arthrographic images show an
isolated superior GHL tear (arrow). The superior GHL is indistinct (b)
compared with a normal superior GHL (cf d). (Fig 15a and 15b reprinted,
with permission, from reference 26.) (c) Arthroscopic photograph demonstrates fraying of the superior GHL at its origin (arrow). H = humeral head.
(d) Oblique sagittal fat-saturated T1-weighted MR arthrographic image obtained in a healthy 15-year-old girl shows the superior GHL (arrowhead)
with a normal smooth low-signal-intensity appearance. (Reprinted, with permission, from reference 26.)
Habermeyer et al (12) studied the factors influencing the development of ASI and subdivided
pulley lesions into four different patterns (Fig
14). Group 1 lesions were defined as isolated
superior GHL lesions (Fig 15); group 2, as superior GHL lesions with a partial articular-side
supraspinatus tendon tear (Fig 16); group 3, as
802 May-June 2011
radiographics.rsna.org
Figure 16. Habermeyer group 2 lesion in a 49-year-old woman. (a) Axial fat-saturated T1weighted MR arthrographic image shows an arthroscopically confirmed superior GHL tear (arrow).
(b) Oblique coronal fat-saturated T1-weighted MR arthrographic image shows a supraspinatus tendon tear (arrowhead).
Figure 17. Habermeyer group 3 lesion in a
37-year-old man. (a, b) Axial (a) and oblique
sagittal (b) fat-saturated T1-weighted MR
arthrographic images demonstrate a superior
GHL tear (arrow). (c) Axial fat-saturated T1weighted MR arthrographic image obtained
slightly caudad to a demonstrates a partial
articular-side subscapularis tendon tear
(arrowhead).
superior GHL lesions with a partial articularside subscapularis tendon tear (Figs 17, 18); and
group 4, as superior GHL lesions with partial
articular-side tears of both the supraspinatus
and subscapularis tendons (Fig 19). ASI was
seen more often in patients with an additional
articular-side tear of the supraspinatus tendon
(group 4) or an additional partial articular-side
tear of the subscapularis tendon (group 3) (12).
Acromioclavicular arthritis was also observed
significantly more often in patients with ASI than
in those without ASI, but its association with the
development of ASI remains uncertain (12,18).
None of the patients described in these reports
had a bursal-side rotator cuff tear.
RG • Volume 31
Number 3
Nakata et al
803
Figure 18. Habermeyer group 3 lesion
in a 42-year-old man who sustained a
weightlifting injury. (a) Axial fat-saturated
T1-weighted MR arthrographic image demonstrates an arthroscopically confirmed partial articular-side subscapularis tendon tear
(arrow). (b, c) Oblique sagittal fat-saturated
T1-weighted MR arthrographic image (b)
and corresponding arthroscopic image (c)
show a superior GHL tear (arrow). H = humeral head. (Fig 18b reprinted, with permission, from reference 26.)
Figure 19. Habermeyer group 4 lesion in a 56-year-old man. (a, b) Axial
fat-saturated T1-weighted MR arthrographic images demonstrate an extensive
subscapularis tendon tear with medial dislocation of the LBT (arrow in a) and
a superior GHL tear (arrowhead in b). (Fig 19b reprinted, with permission,
from reference 26.) (c, d) Oblique coronal fat-saturated T1-weighted MR
arthrographic image (c) and corresponding arthroscopic image (d) show a
tear (arrow in c) of the undersurface of the supraspinatus tendon (Ssp). H =
humeral head.
804 May-June 2011
These investigators concluded that a pulley lesion leads to instability of the LBT, which causes
partial articular-side tears of the subscapularis
and supraspinatus tendons (12,18). The medially
dislocated biceps tendon further reinforces anterior and upward translation of the humeral head,
thus resulting in ASI.
Only a few reports have discussed specific
MR imaging criteria for the diagnosis of superior
GHL tears. Chandnani et al (27) retrospectively
correlated MR arthrographic findings with surgical findings in 46 patients to evaluate the efficacy
of MR imaging in the detection of abnormalities
of the GHLs. They evaluated the presence and
integrity of the GHLs and identified associated
abnormalities of the joint capsule and labrum.
The superior GHL was considered to be present
when it could be seen to insert in the superior
portion of the labrum, just anterior to the insertion of the biceps tendon at the level of the base
of the coracoid process, and to be torn when it
was visualized as discontinuous structures on
contiguous images. The superior GHL was identified at MR arthrography in 39 cases (85%), 34
of which were described in surgical reports. MR
arthrography helped correctly identify 29 of the
31 cases of a normal superior GHL and all three
cases of a torn superior GHL. The authors concluded that MR arthrography had a sensitivity of
100%, a specificity of 94%, and an accuracy of
94% in the diagnosis of superior GHL tears (27).
However, their study was limited in that they
evaluated only axial and oblique coronal images
and a relatively small number of cases involving
a superior GHL tear. Vinson et al (28) retrospectively reviewed five surgically proved cases of
rotator interval lesions and compared them with
control cases. They concluded that subjective
thickening and irregularity of the superior GHL
and CHL may be helpful in the diagnosis of rotator interval lesions.
Pathologic Conditions of the Biceps Tendon
The biceps tendon lies within a reflection of the
synovial membrane as it courses down the bicipital groove; thus, it is intraarticular but extrasynovial (5,13). Given the communication of the
tendon sheath with the glenohumeral joint and
its anatomic association with the rotator cuff and
rotator interval, any pathologic process involving
one of these components may also affect other
components.
radiographics.rsna.org
In contradistinction to the function of the biceps tendon at the elbow, its role at the shoulder
is still controversial, and its previously accepted
role as a stabilizer of the humeral head has been
reconsidered (10,13,29). It is important to note
that pathologic conditions of the biceps tendon
have been widely accepted as a source of anterior shoulder pain. These pathologic conditions
include instability, tendinopathy, tendinosis,
and partial or complete biceps tendon rupture
(10,29). Several pathologic processes may coexist, some of which are a consequence of others.
Subluxation and Dislocation.—The association
of dislocation of the biceps tendon with rotator
cuff tears is generally accepted. However, isolated
dislocations of the biceps tendon without rotator cuff injuries (although rare) have also been
reported.
In their retrospective review of 445 surgical
cases, Walch et al (19) defined biceps tendon dislocation as the total and permanent loss of contact between the tendon and the bicipital groove.
They described four types of dislocation: (a) dislocation inside the subscapularis tendon, leaving
the anterior fascia intact; (b) intraarticular dislocation with complete tear of all the insertions
on the lesser tuberosity but intact anterior fascia,
so that the lesion is hidden in the joint space;
(c) intraarticular dislocation with complete tear
of all the insertions on the lesser tuberosity and
anterior fascia; and (d) dislocation over an intact
subscapularis tendon (rupture of the supraspinatus tendon and CHL) (19). All dislocations are
associated with tears of the ligamentous pulley.
The authors found subluxation more difficult
to define because partial or transitional loss of
contact between the biceps tendon and the bicipital groove was not easy to define during surgery. The best arthroscopic sign of subluxation
is fraying of the deep layer of the biceps tendon.
The authors defined subluxation at arthroscopic
computed tomography as occurring when the
biceps tendon appeared fixed over the medial
rim at the superior part of the groove or recentered into the groove before disappearance of the
groove. In the cases of subluxation in their study,
the ligamentous pulley was noted to be intact,
attenuated, or torn. Tear of the supraspinatus
tendon was almost always observed, and a lesion
of the subscapularis tendon was always associated with subluxation (19). In a retrospective review of arthroscopic reports, Bennett (1) classified subluxation into four types according to the
direction of the subluxation: (a) intraarticular,
RG • Volume 31
Number 3
Nakata et al
805
Figure 20. Secondary biceps tendonitis in a 64-year-old woman. (a) Oblique sagittal fat-saturated T2-weighted MR image shows a slightly thickened biceps tendon with a focal fluid collection (arrow) around its bicipital groove portion. (b) Axial gradient-echo T2*-weighted MR image
shows fluid (arrow) completely surrounding the biceps tendon. Rotator cuff impingement (not
shown) was also present, a finding consistent with secondary biceps tendonitis.
(b) between the subscapularis tendon and CHL,
(c) external to the CHL, and (d) intrasheath.
The author stated that the pattern is dependent
on which underlying supporting structures are
injured. Castagna et al (30) reported nine cases
in which pulley system lesions were unclear but
the diagnosis of an unstable biceps tendon was
associated with a “chondral print,” seen at arthroscopy as a line on the anterior part of the
humeral head representing a subluxated biceps
tendon. In chronic subluxation, minimal dynamic medial displacement of the biceps tendon
was difficult to detect with arthroscopy because
of the minimal abnormality in the pulley system.
The authors found the chondral print on the
humeral head helpful in making the correct diagnosis when an associated pulley lesion was not
clearly depicted (30).
At MR imaging, the dislocated biceps tendon
can be identified medial to the empty bicipital
groove, most clearly on axial images. Oblique
coronal and oblique sagittal images are also useful. As mentioned earlier, the displaced biceps
tendon can be identified as either extraarticular
or intraarticular, with a variable degree of injury
to the surrounding structures. At conventional
MR imaging, associated abnormalities of the biceps tendon may manifest as variable degrees of
increased signal intensity, changes in the shape of
the tendon (thickening, flattening, broadening),
and fluid around the displaced biceps tendon.
Other abnormalities associated with dislocation
of the biceps tendon include an abnormal shape
of the bicipital groove, abnormalities of the rotator cuff, disruption of the CHL, disruption and
thinning of the subscapularis tendon, and supraspinatus tendon tear (31,32).
Tendinopathy or Tendinosis.—Secondary biceps
tendinopathy is seen in 95% of patients with
bicipital tendinopathy and is usually associated
with disease of the rotator cuff and impingement
syndrome (13,33). Primary biceps tendinopathy
is diagnosed when other associated pathologic
processes are excluded. Structural anomalies
of the bicipital groove and repeated trauma
are described as causes in young patients, with
degenerative changes being implicated in older
patients (34).
On MR images, tendon diameter changes,
abnormal signal intensity, and associated fluid
collections should be assessed (Fig 20). Thorough observation of the surrounding structures
is also essential for making the correct diagnosis.
In their study of cadaveric shoulders, Buck et
al (35) suggested diameter change as a primary
criterion for the diagnosis of tendon degeneration, although absence of a diameter change
does not mean that there is no abnormality. A
change in signal intensity in the biceps tendon
likely indicates degeneration but is not sufficient
to help differentiate between the various types of
degeneration (eg, mucoid degeneration, lipoid
degeneration). Fluid along the LBT sheath is not
806 May-June 2011
radiographics.rsna.org
Figures 21, 22. (21) Type II SLAP lesion in a 23-year-old male baseball player. (a) Oblique
coronal fat-saturated T1-weighted MR arthrographic image shows a superior labral tear (arrow)
and a partial tear of the undersurface of the supraspinatus tendon (arrowhead). (b) Axial fatsaturated T1-weighted MR arthrographic image shows an attenuated and irregular superior
GHL (arrow). (c) Arthroscopic photograph shows synovitis in the rotator interval. H = humeral
head. (22) Type III SLAP lesion in a 19-year-old male baseball player. (a) Oblique coronal
fat-saturated T1-weighted MR arthrographic image shows a superior labral tear (arrow).
(b) Corresponding arthroscopic photograph shows an avulsed superoanterior glenoid labrum
(arrow). H = humeral head. (c) Axial fat-saturated T1-weighted MR arthrographic image
shows an associated biceps pulley lesion. The superior GHL is irregular (arrowhead).
RG • Volume 31
Number 3
Figure 23. Adhesive capsulitis in a 45-year-old
man. Only 8 mL of contrast material was injected
secondary to pain and elevated intraarticular pressure. Oblique sagittal T1-weighted MR arthrographic image shows the subcoracoid fat triangle
(arrowheads), which is partially obliterated (black
arrow). The borders of the triangle are defined anterosuperiorly by the coracoid process, superiorly
by the CHL (white arrow), and posteroinferiorly
by the joint capsule.
necessarily abnormal, since the tendon sheath
and glenohumeral joint are in direct communication. However, fluid completely surrounding
the tendon may raise suspicion for tenosynovitis,
although anterior circumflex humeral vessels may
mimic fluid in the sheath (36).
Superior Labrum
Anterior and Posterior Lesions
With injuries to the rotator interval and LBT,
superior labrum anterior and posterior (SLAP)
lesions should be suspected. The converse is also
true: The presence of a SLAP lesion suggests
injuries to the rotator interval and LBT. SLAP
lesions were initially reported as clinically significant because the superior labrum serves as an
anchor for the biceps tendon. Thus, it is understandable that the cause of SLAP lesions is similar to those of isolated pulley lesions.
Four types of SLAP lesions were originally
described by Snyder et al (37) on the basis of
arthroscopic findings. A type I lesion is characterized by marked fraying of the superior glenoid
labrum without labral detachment or biceps
tendon injury. A type II lesion consists of labral
fraying with stripping of the superior labrum and
the attachment of the biceps tendon from the
underlying glenoid fossa. A type III lesion is a
“bucket-handle” tear of the superior labrum; the
Nakata et al
807
peripheral portion of the labrum remains firmly
attached to the underlying glenoid fossa and the
biceps tendon remains intact. A type IV lesion is
a bucket-handle tear of the superior labrum that
extends into the biceps tendon. Six additional
classifications have been developed, mainly representing a combination of superior labral tears
with extension into different areas of the labrum
or other adjacent capsuloligamentous components. A type X lesion consists of a superior
labral tear with extension to the rotator interval;
some of the other types involve the biceps anchor
or biceps tendon. It is unclear whether these ten
types of SLAP lesions can be differentiated with
MR imaging, and the mechanisms of injury have
not yet been fully elucidated (38). The original
classification scheme developed by Snyder et al
(37) is still the most widely accepted.
It is important to evaluate the contour and
signal intensity of the superior labrum on oblique
coronal and axial MR images; the superior labrum should be smooth with uniform low signal
intensity. Normal variants can be seen in an area
where disease is also common. Variations in signal
intensity, morphologic features, attachment, and
presence or absence of the labrum may be seen.
For example, transitional zones of the labrum
may have high signal intensity, a Buford complex
can be confused with pathologic detachment, or a
sublabral sulcus-recess may be difficult to differentiate from SLAP lesions (39). Normal variants
and pathologic lesions may coexist. Increased
awareness of these variants may lead to correct
interpretation of the images. A complete review
of SLAP lesions and labral variants is beyond
the scope of this article, but the reader should be
familiar with them, especially since SLAP tears
may be associated with lesions of the biceps pulley and rotator interval (Figs 21, 22).
Adhesive Capsulitis
Idiopathic adhesive capsulitis (Fig 23) is a selflimiting disease that is characterized clinically by
the gradual onset of severe shoulder pain with restricted shoulder motion of unknown cause. Many
terms have been applied to this specific clinical
entity, including frozen shoulder, adhesive capsulitis, stiff and painful shoulder, periarthritis, periarticular adhesions, and pericapsulitis. There is no
single agreed-upon criterion for establishing the
diagnosis of this condition; instead, the diagnosis is
made on the basis of clinical history and physical
examination findings. Synovial inflammation with
808 May-June 2011
subsequent reactive capsular fibrosis may be the
underlying pathologic changes (40,41). Adhesive
capsulitis may be associated with (a) diabetes mellitus; (b) conditions such as Dupuytren disease;
(c) hyper- or hypothyroidism; (d) cerebral, cardiac, and respiratory conditions; and (e) surgical
procedures that do not directly affect the shoulder, such as cardiac surgery (42,43). Any other
pathologic conditions of the shoulder that could
cause secondary capsular adhesions and contracture should be excluded. Such conditions include
rotator cuff disease, calcific deposits, biceps tendinopathy or tear, rheumatoid arthritis, hemiplegia,
postsurgical scarring, and posttraumatic stiffness
with or without a fracture (40,42).
Conventional shoulder arthrography has long
been considered the standard imaging study for
establishing the diagnosis of adhesive capsulitis.
Decreased joint volume of less than 10 mL, pain
after the injection of less than 10 mL of contrast
material, and marked loss of the normal axillary
fold are seen in patients with adhesive capsulitis
(40,44).
Recent studies have shown the usefulness of
other imaging modalities such as conventional MR
imaging, ultrasonography, and nuclear medicine
imaging (45,46). There have been reports establishing the criteria for determining the diagnosis
of adhesive capsulitis at conventional MR imaging
(47) as well as at direct and indirect MR arthrography (43,44,48). Thickening of the joint capsule
in the axillary recess has been described as a characteristic sign of adhesive capsulitis (48), but not
all investigators agree that it is an accurate sign
(43,47). There have been many arthroscopic studies showing inflammation in the rotator interval,
synovitis at the anterosuperior glenohumeral joint,
and thickening of the CHL as more definitive for
the diagnosis (41). Mengiardi et al (43) described
(a) thickening of the CHL and the capsule at
the rotator interval and (b) complete obliteration
of the fat triangle under the coracoid process as
the most characteristic MR imaging findings in
adhesive capsulitis. Some researchers have found
that the coefficient of enhancement (ie, the rate
of increase in signal intensity on dynamic contrast
material–enhanced MR images) correlates with the
level of inflammatory activity of the synovium (49).
Making a diagnosis of adhesive capsulitis is
difficult with MR imaging performed to evaluate
a painful shoulder, but recognition of this disorder may have an important effect on medical and
surgical treatment.
radiographics.rsna.org
Subcoracoid Bursa
The capsule of the glenohumeral joint usually
has at least two openings: (a) below the coracoid process, connecting the joint to a bursa
behind the subscapularis tendon (anterior); and
(b) between the humeral tubercles, transmitting
the long tendon of the biceps muscle and its
synovial sheath, connecting the joint to a bursa
under the infraspinatus tendon (posterior and
inconstant) (Fig 4) (3).
The recess that projects anteriorly between
the superior and middle GHLs is called the
superior subscapularis recess or subscapularis
bursa. This recess lies between the subscapularis
muscle and the anterior surface of the scapula
and extends above the superior margin of the
subscapularis tendon. Because this is not a separate bursa, fluid within this recess may be simply physiologic. On the other hand, fluid in the
subcoracoid bursa may represent a pathologic
process. The subcoracoid bursa lies between
the anterior surface of the subscapularis muscle
and the coracoid process. It extends along the
tendon formed by the merger of the coracobrachialis tendon and the short head of the biceps
tendon. This bursa normally communicates,
not with the glenohumeral joint, but with the
subacromial-subdeltoid bursa (50,51).
Grainger et al (50) retrospectively reviewed
imaging reports from 1831 shoulder MR imaging
examinations and identified 16 patients who were
reported to have subcoracoid bursa effusions.
Rereview of the MR images revealed that 13 of
these patients actually had fluid collections in the
subcoracoid bursa. A rotator cuff tear was seen in
all cases, and a rotator interval tear was seen in
11 patients. Although the superior subscapularis
recess and the subcoracoid bursa may be difficult
to visualize on axial images, the authors found
oblique sagittal images to be useful in differentiating between the two (Fig 24) (50).
The clinical significance of fluid in the subcoracoid bursa is uncertain. However, there have
been some reports on the association of such
fluid with tears of the rotator cuff and rotator
interval (50,51). The effusion may represent isolated subcoracoid bursitis, inadvertent injection
of contrast material into the bursa (which, if not
recognized, could result in an erroneous diagnosis because of the communication between the
bursa and the joint with a complete rotator cuff
tear), or a posttraumatic inflammatory response.
When an effusion is identified, the rotator cuff
and rotator interval should be carefully evaluated
for possible tears.
RG • Volume 31
Number 3
Nakata et al
809
References
Figure 24. Subcoracoid bursa. Oblique sagittal
T2-weighted MR arthrographic image shows a
superior subscapularis recess (arrow) and subcoracoid bursa (*) located anterior to the subscapularis muscle (S). Note the caudal extent
of the subcoracoid bursa and the fibrous septum
(arrowhead) separating the two fluid-filled spaces.
T = coracobrachialis tendon and the short head of
the biceps tendon.
Conclusions
The biceps pulley consists of the CHL, the superior GHL, and fibers from the subscapularis
tendon. These constituents are distinct anatomic structures, yet their fibers merge to form
a functional unit that stabilizes the LBT and the
glenohumeral joint. Not only the biceps pulley, but also the surrounding musculotendinous
structures (LBT, glenoid labrum, biceps anchor,
rotator cuff) should be considered as constituting
a functional and anatomic unit. MR arthrography
effectively demonstrates the normal anatomy and
pathologic conditions of this area, as well as associated findings. Oblique sagittal and axial images
should be obtained for the evaluation of pulley
lesions.
Injury to the anterosuperior aspect of the
shoulder is better understood as part of a spectrum of processes than as an isolated lesion.
When an abnormality of one of the system components is suspected, thorough radiologic assessment of the entire system is especially important.
Familiarity with the cause, classification, and direction of the injury may be useful for identifying
and characterizing such abnormalities.
Acknowledgments.—The authors are deeply grateful
to Kazuhide Suzuki, MD, and Shigeo Ookawara, MD,
for their support.
1. Bennett WF. Subscapularis, medial, and lateral
head coracohumeral ligament insertion anatomy:
arthroscopic appearance and incidence of “hidden”
rotator interval lesions. Arthroscopy 2001;17(2):
173–180.
2. Cole BJ, Warner JJP. Anatomy, biomechanics, and
pathophysiology of glenohumeral instability. In: Iannotti JP, Williams GR, eds. Disorders of the shoulder:
diagnosis and management. Philadelphia, Pa: Lippincott Williams & Wilkins, 1999;207–232.
3. Johnson D. Gray’s anatomy. Philadelphia, Pa:
Churchill Livingstone Elsevier, 2008.
4. Clark J, Sidles JA, Matsen FA. The relationship of
the glenohumeral joint capsule to the rotator cuff.
Clin Orthop Relat Res 1990;(254):29–34.
5. Yamaguchi K, Bindra R. Disorders of the biceps
tendon. In: Iannotti JP, Williams GR, eds. Disorders
of the shoulder: diagnosis and management. Philadelphia, Pa: Lippincott Williams & Wilkins, 1999;
159–190.
6. Sher JS. Anatomy, biomechanics, and pathophysiology of rotator cuff disease. In: Iannotti JP, Williams GR, eds. Disorders of the shoulder: diagnosis
and management. Philadelphia, Pa: Lippincott Williams & Wilkins, 1999; 3–29.
7. Ho CP. MR imaging of rotator interval, long biceps,
and associated injuries in the overhead-throwing
athlete. Magn Reson Imaging Clin N Am 1999;7
(1):23–37.
8. Jost B, Koch PP, Gerber C. Anatomy and functional
aspects of the rotator interval. J Shoulder Elbow
Surg 2000;9(4):336–341.
9. Lee JC, Guy S, Connell D, Saifuddin A, Lambert
S. MRI of the rotator interval of the shoulder. Clin
Radiol 2007;62(5):416–423.
10. Sethi N, Wright R, Yamaguchi K. Disorders of the
long head of the biceps tendon. J Shoulder Elbow
Surg 1999;8(6):644–654.
11. Yang HF, Tang KL, Chen W, et al. An anatomic and
histologic study of the coracohumeral ligament. J
Shoulder Elbow Surg 2009;18(2):305–310.
12. Habermeyer P, Magosch P, Pritsch M, Scheibel MT,
Lichtenberg S. Anterosuperior impingement of the
shoulder as a result of pulley lesions: a prospective
arthroscopic study. J Shoulder Elbow Surg 2004;13
(1):5–12.
13. Curtis AS, Snyder SJ. Evaluation and treatment of
biceps tendon pathology. Orthop Clin North Am
1993;24(1):33–43.
14. Gleason PD, Beall DP, Sanders TG, et al. The transverse humeral ligament: a separate anatomical structure or a continuation of the osseous attachment
of the rotator cuff? Am J Sports Med 2006;34(1):
72–77.
15. MacDonald K, Bridger J, Cash C, Parkin I. Transverse humeral ligament: does it exist? Clin Anat
2007;20(6):663–667.
16. Chung CB, Dwek JR, Cho GJ, Lektrakul N, Trudell
D, Resnick D. Rotator cuff interval: evaluation with
MR imaging and MR arthrography of the shoulder
in 32 cadavers. J Comput Assist Tomogr 2000;24
(5):738–743.
810 May-June 2011
17. Wutke R, Fellner FA, Fellner C, Stangl R, Dobritz
M, Bautz WA. Direct MR arthrography of the shoulder: 2D vs. 3D gradient-echo imaging. Magn Reson
Imaging 2001;19(9):1183–1191.
18. Baumann B, Genning K, Böhm D, Rolf O, Gohlke
F. Arthroscopic prevalence of pulley lesions in 1007
consecutive patients. J Shoulder Elbow Surg 2008;
17(1):14–20.
19. Walch G, Nové-Josserand L, Boileau P, Levigne
C. Subluxations and dislocations of the tendon of
the long head of the biceps. J Shoulder Elbow Surg
1998;7(2):100–108.
20. Nobuhara K, Ikeda H. Rotator interval lesion. Clin
Orthop Relat Res 1987;(223):44–50.
21. Rowe CR, Zarins B. Recurrent transient subluxation
of the shoulder. J Bone Joint Surg Am 1981;63(6):
863–872.
22. Le Huec JC, Schaeverbeke T, Moinard M, et al.
Traumatic tear of the rotator interval. J Shoulder
Elbow Surg 1996;5(1):41–46.
23. Field LD, Warren RF, O’Brien SJ, Altchek DW,
Wickiewicz TL. Isolated closure of rotator interval
defects for shoulder instability. Am J Sports Med
1995;23(5):557–563.
24. Nidecker A, Gückel C, von Hochstetter A. Imaging
the long head of biceps tendon: a pictorial essay emphasizing magnetic resonance. Eur J Radiol 1997;25
(3):177–187.
25. Gerber C, Sebesta A. Impingement of the deep surface of the subscapularis tendon and the reflection
pulley on the anterosuperior glenoid rim: a preliminary report. J Shoulder Elbow Surg 2000;9(6):
483–490.
26. Nakata W, Kato S, Sugimoto H. MR imaging of the
rotator interval, long head of biceps, and biceps pulley of the shoulder. Jpn J Diagn Imaging 2009;(29):
649–705.
27. Chandnani VP, Gagliardi JA, Murnane TG, et al.
Glenohumeral ligaments and shoulder capsular
mechanism: evaluation with MR arthrography.
Radiology 1995;196(1):27–32.
28. Vinson EN, Major NM, Higgins LD. Magnetic
resonance imaging findings associated with surgically proven rotator interval lesions. Skeletal Radiol
2007;36(5):405–410.
29. Ahrens PM, Boileau P. The long head of biceps
and associated tendinopathy. J Bone Joint Surg Br
2007;89(8):1001–1009.
30. Castagna A, Mouhsine E, Conti M, et al. Chondral
print on humeral head: an indirect sign of long head
biceps tendon instability. Knee Surg Sports Traumatol Arthrosc 2007;15(5):645–648.
31. Cervilla V, Schweitzer ME, Ho C, Motta A, Kerr
R, Resnick D. Medial dislocation of the biceps brachii tendon: appearance at MR imaging. Radiology
1991;180(2):523–526.
32. Chan TW, Dalinka MK, Kneeland JB, Chervrot A.
Biceps tendon dislocation: evaluation with MR imaging. Radiology 1991;179(3):649–652.
33. Post M, Benca P. Primary tendinitis of the long head
of the biceps. Clin Orthop Relat Res 1989;(246):
117–125.
34. Depalma AF, Callery GE. Bicipital tenosynovitis.
Clin Orthop Relat Res 1954;3:69–85.
radiographics.rsna.org
35. Buck FM, Grehn H, Hilbe M, Pfirrmann CW,
Manzanell S, Hodler J. Degeneration of the long
biceps tendon: comparison of MRI with gross anatomy and histology. AJR Am J Roentgenol 2009;193
(5):1367–1375.
36. Kaplan PA, Bryans KC, Davick JP, Otte M, Stinson WW, Dussault RG. MR imaging of the normal
shoulder: variants and pitfalls. Radiology 1992;184
(2):519–524.
37. Snyder SJ, Karzel RP, Del Pizzo W, Ferkel RD,
Friedman MJ. SLAP lesions of the shoulder. Arthroscopy 1990;6(4):274–279.
38. Mohana-Borges AV, Chung CB, Resnick D. Superior labral anteroposterior tear: classification and
diagnosis on MRI and MR arthrography. AJR Am J
Roentgenol 2003;181(6):1449–1462.
39. Chang D, Mohana-Borges A, Borso M, Chung CB.
SLAP lesions: anatomy, clinical presentation, MR
imaging diagnosis and characterization. Eur J Radiol
2008;68(1):72–87.
40. Neviaser RJ, Neviaser TJ. The frozen shoulder: diagnosis and management. Clin Orthop Relat Res
1987;(223):59–64.
41. Ozaki J, Nakagawa Y, Sakurai G, Tamai S. Recalcitrant chronic adhesive capsulitis of the shoulder:
role of contracture of the coracohumeral ligament
and rotator interval in pathogenesis and treatment. J
Bone Joint Surg Am 1989;71(10):1511–1515.
42. Manske RC, Prohaska D. Diagnosis and management of adhesive capsulitis. Curr Rev Musculoskelet Med 2008;1(3-4):180–189.
43. Mengiardi B, Pfirrmann CW, Gerber C, Hodler
J, Zanetti M. Frozen shoulder: MR arthrographic
findings. Radiology 2004;233(2):486–492.
44. Manton GL, Schweitzer ME, Weishaupt D, Karasick D. Utility of MR arthrography in the diagnosis
of adhesive capsulitis. Skeletal Radiol 2001;30(6):
326–330.
45. Binder AI, Bulgen DY, Hazleman BL, Tudor J,
Wraight P. Frozen shoulder: an arthrographic and
radionuclear scan assessment. Ann Rheum Dis
1984;43(3):365–369.
46. Lee JC, Sykes C, Saifuddin A, Connell D. Adhesive
capsulitis: sonographic changes in the rotator cuff
interval with arthroscopic correlation. Skeletal Radiol 2005;34(9):522–527.
47. Connell D, Padmanabhan R, Buchbinder R. Adhesive capsulitis: role of MR imaging in differential
diagnosis. Eur Radiol 2002;12(8):2100–2106.
48. Jung JY, Jee WH, Chun HJ, Kim YS, Chung YG,
Kim JM. Adhesive capsulitis of the shoulder: evaluation with MR arthrography. Eur Radiol 2006;16(4):
791–796.
49. Tamai K, Yamato M. Abnormal synovium in the
frozen shoulder: a preliminary report with dynamic
magnetic resonance imaging. J Shoulder Elbow Surg
1997;6(6):534–543.
50. Grainger AJ, Tirman PF, Elliott JM, Kingzett-Taylor
A, Steinbach LS, Genant HK. MR anatomy of the
subcoracoid bursa and the association of subcoracoid effusion with tears of the anterior rotator cuff
and the rotator interval. AJR Am J Roentgenol 2000;
174(5):1377–1380.
51. Schraner AB, Major NM. MR imaging of the subcoracoid bursa. AJR Am J Roentgenol 1999;172(6):
1567–1571.
Teaching Points
May-June Issue 2011
Biceps Pulley: Normal Anatomy and Associated Lesions at MR Arthrography
Waka Nakata, MD • Sakura Katou, MD • Akifumi Fujita, MD • Manabu Nakata, MD • Alan T. Lefor, MD,
MPH • Hideharu Sugimoto, MD
RadioGraphics 2011; 31:791–810 • Published online 10.1148/rg.313105507 • Content Codes:
Page 797
The medial band of the CHL and the superior GHL inserting on the lesser tuberosity, together with the
superior fibers from the subscapularis tendon, act as a pulley to stabilize the biceps tendon in the bicipital groove. This entity is also referred to as the biceps reflective pulley or sling (7,9,10,12).
Page 799 (Figure on page 797)
Oblique sagittal images obtained parallel to the plane of the glenoid fossa and orthogonal to the long axis
of the rotator cuff are thought to be the best for evaluating the rotator interval and its contents (Fig 9)
(7). Axial images are also valuable for identifying the biceps pulley complex, along with the biceps tendon
within the proximal bicipital groove.
Page 799
Disease affecting any of the rotator interval components may be part of a complex spectrum of pathologic conditions. Injury to any of these components requires that the entire rotator interval system be
evaluated.
Page 799 (Figure 12 on page 798, figure 13 on page 800)
A pulley lesion can be caused by degenerative changes, acute trauma, repetitive microtrauma, or injury
associated with a rotator cuff tear (Figs 12, 13).
Page 804
A pulley lesion leads to instability of the LBT, which causes partial articular-side tears of the subscapularis and supraspinatus tendons (12,18). The medially dislocated biceps tendon further reinforces anterior and upward translation of the humeral head, thus resulting in ASI.